VA TENNESSEE VALLEY HEALTHCARE SYSTEM
DEPARTMENT OF ANESTHESIOLOGY
APPLICATION FOR CLINICAL PRIVILEGES
Date Reviewed and Approved by PSB
Privileges Approved
From: _____________ To: _________________
(To be completed by Credentialing Staff only)
Name of Practitioner ________________________________________________________
Last
First
Middle
Type of Request: Check Appropriate Box
Initial
Biennial Renewal
Change in Privileges
Change in Category of Staff Membership
Category of Staff Membership: Check Appropriate Box
Full Time Staff
On-Station Fee Basis
Part Time Staff
On-Station Contract
Consultation/Attending
On-Station Sharing Agreement
Without Compensation (WOC)
SETTING OF PRIVILEGES. (Check Appropriate Box)
Nashville (Inpatient, Outpatient, ED, ICU, OR, Procedure Areas)
York (Inpatient, Outpatient, ED, ICU, OR, Procedure Areas)
CBOC (COPC Outpatient)
Eligibility Criteria: To be eligible to request clinical privileges, the applicant must meet the following minimum
criteria (specialty specific):
1.
Basic Education: Doctor of Medicine or Doctor of Osteopathic Medicine from an accredited medical school
(or equivalent)
2. Minimum Formal Training: Completion of Anesthesiology residency
3. Basic Life Support (BLS) Training
4. Advanced Critical Life Support (ACLS) Training
5. Previous Experience: A letter of reference must come from a peer, department chair or program director with
whom the physician has been affiliated.
6. Board Certification: Board Certification or Eligibility is preferred by the American Board of Anesthesiology
and subspecialty where indicated.
BACKGROUND: Anesthesiology is the practice of medicine dealing with, but not limited to, the provision of
insensibility to pain during surgical, obstetric, therapeutic and diagnostic procedures, and the management of
patients so affected; the monitoring and restoration of homeostasis in the critically ill, unconscious, injured, or
otherwise seriously ill patient; the diagnosis and treatment of acute and chronic painful syndromes, in addition to
perioperative pain management; the clinical management and teaching of cardiac and pulmonary resuscitation; the
evaluation of respiratory function and application of respiratory therapy and mechanical ventilation in all its forms;
the supervision of both medical and paramedical personnel involved in anesthesia, respiratory therapy, and critical
care; and the conducting of research at the clinical and basic science levels to explain and improve the care of
patients.
Applicant Name: _________________________________
Last 4 of SSN: _______
Page 1 of 4
VA TENNESSEE VALLEY HEALTHCARE SYSTEM
DEPARTMENT OF ANESTHESIOLOGY
APPLICATION FOR CLINICAL PRIVILEGES
CORE PRIVILEGES
Core privileges are to include comprehensive medical management of patients to be rendered unconscious or insensitive
to pain during surgical, dental and certain medical procedures within the operating room as well as outside the operating
room. Core privileges also include preoperative, intraoperative, and postoperative examination, consultation,
management, monitoring, evaluation, and treatment:
 Management of fluid, electrolyte, and metabolic parameters
 Resuscitation of patients of all ages
 Management of malignant hyperthermia
 Manipulation of body temperature
 Diagnostic and therapeutic management of acute and chronic pain
 Manipulation of cardiovascular parameters
 Management of hypovolemia from any cause
 Monitored anesthesia care
 Sedation and analgesia
 Management of unconscious patients
Procedures:
 Administration of General Anesthesia (Inhalation and Intravenous) including invasive
monitoring
 Administration of Regional Anesthesia with and without ultrasound guidance including:
Spinal, epidural, and peripheral nerve blocks
 Placement of venous catheters both with and without ultrasound guidance.
 Placement of arterial catheters both with and without ultrasound guidance and
interpretation of arterial pressures
 Placement of pulmonary artery catheters with and without ultrasound guidance and
interpretation of pressures/wave forms
 Airway management including cricothyroidotomy
 Management of ventilator dependent patients
 One lung anesthesia
 Proficiency in basic Transesophegeal Echocardiography
Supervision of CRNA staff, physician residents, and medical students in the comprehensive medical management of all
patient care is included in these core privileges.
GRAY OUT AS APPROPRIATE FOR YORK, NASHVILLE AND COPC
SUPPLEMENTAL
PRIVILEGES
REQUESTED PRIVILEGES
NASHVILLE
CAMPUS
YES
NO
YORK
CAMPUS
YES NO
RECOMMENDED APPROVAL
COPC
YES
NO
SERVICE
CHIEF
YES
NO
PSB APPROVAL
YES
NO
Permanent Nerve
Blocks
Cryotherapeutic
Techniques
Dorsal root entry
zone lesions
Electrical
stimulation
techniques
Implanted epidural
and intrathecal
catheters, ports,
and infusion
pumps
Applicant Name: _________________________________
Last 4 of SSN: _______
Page 2 of 4
DATE
VA TENNESSEE VALLEY HEALTHCARE SYSTEM
DEPARTMENT OF ANESTHESIOLOGY
APPLICATION FOR CLINICAL PRIVILEGES
SUPPLEMENTAL
PRIVILEGES
REQUESTED PRIVILEGES
NASHVILLE
YORK
COPC
CAMPUS
CAMPUS
YES
NO
YES
NO
YES
NO
RECOMMENDED APPROVAL
SERVICE
PSB APPROVAL
CHIEF
YES
NO
YES NO
DATE
Peripheral
neurectomy and
neurolysis
Radiofrequency
ablations under
fluoroscopy
Critical care
medicine
Multidisciplinary
direction of pain
management
Hypothermic
arrest
Cardiopulmonary
bypass
Circulatory arrest
Transesophageal
echocardiography
Sympathetic Block
Bier Block
Trigger Point
Injection
Joint Injection
Buria Injection
RACZ Procedure
Vertebroplasty
Kyphoplasty
Discogram
IDET
Acutherm
Percutaneous
Disctomy
Admitting
Other: (list)
(Add rows as needed)
Applicant Name: _________________________________
Last 4 of SSN: _______
Page 3 of 4
VA TENNESSEE VALLEY HEALTHCARE SYSTEM
DEPARTMENT OF ANESTHESIOLOGY
APPLICATION FOR CLINICAL PRIVILEGES
I ACKNOWLEDGE THAT I HAVE BEEN FURNISHED WITH A COPY OF THE CURRENT MEDICAL
STAFF BYLAWS, AND I HEREBY AGREE TO ABIDE BY THEM. I ALSO AGREE TO PROVIDE
CONTINUOUS CARE TO PATIENTS ASSIGNED TO ME AND ARRANGE FOR THE TRANSFER OF
CARE AS APPROPRIATE. I CERTIFY THAT I HAVE HAD APPROPRIATE EXPERIENCE AND/OR
TRAINING AND I AM PHYSICALLY AND MENTALLY COMPETENT TO PERFORM THE CLINICAL
PRIVILEGES REQUESTED.
 YES
 NO
______________________________________/____________________________________ /________________
(Applicant’s Signature)
Typed/Printed Name
Date
Standards for Granting and Renewing Privileges section (to be completed by the Service Chief or Designee):
1. Does the practitioner comply with general requirements for continuing education, maintaining certification, and
meeting minimum levels of activity?
Yes
No
2. Does the practitioner correctly perform procedures and processes that are his or her direct responsibility,
including appropriate selection of, compliance with, and departure from protocols? (Practitioner to provide a list of
procedures and processes to the Service Chief.)
Yes
No
3. Does the practitioner achieve outcomes consistent with the expectations of the community, with due
consideration of differences in the population being treated?
Yes
No
4. Has the practitioner respected the rights and safety of patients and colleagues?
Yes
No
I recommend privileges requested, except as noted:
___________________________________________/________________
Ann Walia, MD
Date
Chief, Anesthesiology Service
__________________________________________/________________
Roger C. Jones, M.D., FACP
Date
Chairperson PSB/Chief of Staff
Approve / Disapprove PSB Recommendation
________________________________________ /__________________
JUAN A. MORALES, RN, MSN
Date
Health System Director
Applicant Name: _________________________________
Effective no later than
Last 4 of SSN: _______
Page 4 of 4